2127345832 2026

1. Click ‘Get Form’ to open the Foot Referral Form in the editor.
2. Begin by entering the appointment date and time in the designated fields at the top of the form.
3. Fill in the Precert./Ref. #’s section to ensure proper scheduling and authorization.
4. Provide patient details including name, date of birth, and contact number in the respective fields.
5. Indicate the referring physician's name and select any necessary report options such as 'Stat report' or 'Send report (routine)'.
6. Complete sections for imaging requests, specifying areas of concern for MRI, X-Ray, or Ultrasound as needed.
7. Review all entries for accuracy before saving or printing your completed form.

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